Some radiology pearls concerning ankle pain and fractures courtesy of David Bostick and Michael Abraham
Maisonneuve fracture – fracture of the medial malleolus with disruption of the tibiofibular syndesmosis with associated fracture of the proximal fibular shaft (http://radiopaedia.org/articles/maisonneuve-fracture)
When to look for high fibular fracture
Always look for avulsion fracture of 5th metatarsal styloid in patients with ankle pain and
no obvious fractures
Dans-Weber Classification – for lateral malleolar fractures (http://radiopaedia.org/articles/ankle-fracture-classification-weber)
Patellar tendonitis aka jumpers knee
Activity related knee pain due to degenerative, micro injury rather than an inflammatory process
Up to 20% in jumping athletes
Anterior knee pain during or after activity
Bassett Sign:
a) Tenderness to palpation with knee in full extension (patellar tendon relaxed)
b) No tenderness with knee in flexion (patellar tendon tight)
Is there any benefit to the use of prednisone in the treatment of lower back pain? One study showed that about 5% of patients receive prednisone for the treatment of their low back pain, but does it work.
A recent study by Eskin et al published in the Journal of Emergency Medicine looked at this question. They conducted a randomized controlled trial of 18-55 year olds with moderately severe low back. Patients were randomized to receive prednisone 50mg for 5 days or placebo.
The study enrolled a total of 79 patients, and 12 were lost to follow up. At followup there was no difference in their pain, or in them resuming normal activities, returning to work, or days lost from work. To make matters worse more patients in the prednisone group sought additional medical treatment 40% versus 18%.
Conclusion: With the results of this study we should continue the treatment of low back pain with non-steroidials, muscle relaxants and exercise. There does not appear to be any role for steroids in the treatment of these patients.
Return to Play After Infectious Mononucleosis (IM)
-Long incubation period make it difficult to determine source or onset
Presentation often atypical with nothing more than fatigue, decreased energy or decreased athletic performance.
DDX: Herpes simplex, HIV, CMV, toxo and strep (simultaneous infection may be seen in up to 30%)
Classic 3 to 5 day prodromal period (malaise, fatigue, anorexia)
Symptoms then progress into the classic “triad” of IM
Fever, pharyngitis, lymphadenopathy (esp. posterior cervical nodes)
May also have posterior palantine petechiae ( of cases), jaundice, exudative pharyngitis, rash and splenomegaly)
Rash (10% to 40%), transient, generalized maculopapular, petechial or urticarial)
Most commonly seen in patients treated with PCN antibiotics
Splenomegaly is an important complication in the athletic population
Mononucleosis makes the spleen susceptible to rupture (traumatic or spontaneous)
- Lymphocytic proliferation enlarges the spleen beyond protection from the ribs
- Physical examination has been shown to be unreliable for determining splenomegaly
- Highest risk is in the first 21 days (rare after 28 days)
Ultrasound is the modality of choice
-Splenomegaly peaks at 2 to 3 weeks and resolves in the majority between 4 to 6 weeks
Return to play is generally allowed after 4 weeks from diagnosis in the absence of splenomegaly and resolution of symptoms.
Cervical Cord Neuropraxia (CCN)
A concussion of the spinal cord as a result of an on-field collision.
A transient motor and/or sensory disturbance, lasting less than 24 hours.
A distinct and separate entity from spinal cord injury resulting in quadriplegia
Incidence 7.3 per 10,000 athletes
Approx. 50% of players experiencing CCN who return to play, have a second episode
The risk of this second episode is inversely proportional to the size of the cervical bony canal
Athletes with narrow canal diameter are more likely to have a 2nd episode
Those with normal canal diameter (14 mm on MRI) have a 5% risk
Those with a narrow canal (9 mm or less)) have a greater than 50% risk.
Whether repeat episodes lead to permanent spinal cord injury is unknown
Football helmets
A review of head and neck injuries from football from 1959 to 1963 found the rates of intracranial hemorrhage /intracranial death were 2-3X higher than the rates of cervical spine fracture/dislocation or cervical quadriplegia. In contrast, a study of football injuries from 1971 to 1975, revealed a dramatic reversal in rates. Cervical injuries now exceeded the rate of ICH by 2-4X.
A 66% reduction in ICH
A 42% reduction in craniocerebral deaths
A 204% increase in cervical spine fractures and dislocations
The shift was attributed to the modern football helmet, whose superior protection promoted “spearing” (headfirst tackling technique). Spearing involves hitting with the crown of the helmet leading to axial loading of the spine. Spearing accounted for 52% of the quadriplegia injuries from 1971 to 1975. Research by Joesph Torg, M.D., resulted in rule changes that led to an immediate 50% reduction in quadriplegia in NCAA football.
As a parent, coach or team physician, teach and enforce proper form and protect our young athletes.
Some quick facts about Knee Injuries:
When examining a knee for a meniscal injury the commonly described tests are the McMurray Test and Apley Test. However, these tests have sensitivities of 48-68% and 41% respectfully, and specificities of 86-94% and 86-93% respectfully. Depending on whether you are looking at the medical or lateral meniscus.
The Thessaly Test that was first described in 2005 can be performed with knee in either 5 or 20 degrees of flexion and has a senstivity of 89-92% and specificity of 96-97% when performed in 20 degrees flexion. The test also tends to be easier to perform.
To perform the test:
Essentially you and your patient will look like you are doing the twist as they rotate their knee with you holding their hands.
A video of the technique can be found at http://youtu.be/R3oXDvagnic
Lisfranc Fracture:
Typically consists of a fracture of the base of the second metatarsal and dislocation, though it can also be associated with fractures of a cuboid. Common current mechanism of injury is when a person steps into a hole and twists the foot. The original mechanism of injury that was described was when a horseman would fall of their horse with their foot still trapped in a stirrup.
Diagnosis should be considered if patient has difficultly weight bearing with pain on palpation over the 2nd and 3rd metacarpal head with an appropriate mechanism.
Pearls:
Risk Modifiers for Concussion and Prolonged Recovery
A history of prior concussion is a risk factor for future concussion (>2x risk).
For individual sports, boxing has the highest risk.
For team sports, football, ice hockey and rugby have the highest risk.
Women’s soccer confers the highest risk for female athletes.
Younger age confers increased risk.
Female sex confers higher risk when comparing similar sports with similar rules.
Those with migraine headaches may be at increased risk.
Risk of prolonged concussion
Most athletes have symptom resolution within one week
Post traumatic amnesia (both retrograde and anterograde) predict increased number and longer duration of symptoms.
Younger age also predicts pronged recovery.
Other studies have found associations with headache lasting greater than 60 hours, fatigue, “fogginess,” or greater than 3 symptoms at initial presentation. Cognitive studies have identified deficits in visual memory and process speed as predictors of prolonged recovery.
DeQuervain and Intersection Syndromes:
Ankle Syndesmosis Injuries are also called high ankle sprains as they involve trauma to the ligaments above the ankle joint
Most ankle sprains are lateral ankle sprains. High ankle sprains are relatively uncommon.
Usual mechanism: External rotation injuries
Exam: Tenderness at the syndesmosis and compression of the tib/fib at the mid calf level causing syndesmosis pain (squeeze test)
Median recovery time is almost 4 times as long as a lateral ankle sprain 62days vs. 15days
Emergency department care is similar tto that of other ankle sprains but the added benefit of patient education and advice may improve overall care and follow-up.
Herpes Gladiatorum in Wrestlers
HSV causes non genital cutaneous infections primarily in wrestlers, commonly called herpes gladiatorum (HG)
Annual incidence in NCAA wrestlers is 20% to 40%
Most common cutaneous infection leading to lost practice time (40.5% of all infections)
Transmission is skin to skin.
Incubation period is 4 to 7 days from exposure. Healing usually occurs within 10 days after the initial lesion (without scaring).
Appearance: Numerous grouped uncomfortable (painful) vesicles/pustules on an erythematous base…evolve into moist ulcerations, followed by crusted plaques. Lesions typically get abraded during competition therefore may have an atypical appearance and may be mistaken for other infections such as staph. Distribution typically more diffuse than typical HSV infections. Occurs on body surfaces areas that typically come into contract with opponents (face, head, neck, ears, upper extremities). Lesion location typically on side of patient’s handedness. Recurrences occur at location of initial outbreak, a useful diagnostic aid.
Perform a thorough examination as ocular involvement was seen in 8% of high school wrestlers in one HG outbreak.
Typical treatment for primary infection is Valacyclovir 1g PO b.i.d. for 7 days. This is best started within 24h of symptom onset.
The clinical examination is often unreliable in ruling out septic arthritis in the ED.
Diagnostic arthrocentesis is often performed.
Traditional teaching involved very high WBC count thresholds as part of diagnosis.
In one 2009 study, synovial leukocyte counts in cases of MRSA were often less than 25,000 cells/uL
Have a low threshold for empiric antibioitics even in the face of low WBC counts (and incredulous consultants)
Overtraining syndrome
A maladaptive response to excessive exercise without adequate functional rest
-Results in disturbances of multiple body systems (neurologic, endocrinologic, immunologic and psychologic).
- May be caused by systemic inflammation and resultant neurohormonal changes
- Multiple hypotheses exist
-Symptoms
Parasympathetic alterations: fatigue, depression, bradycardia
Sympathetic alterations: insomnia, irritability, agitation, tachycardia, hypertension, restlessness
Other: anorexia, weight loss, poor concentration, anxiety
Usual presentation is prolonged underperformance despite adequate rest and recovery (weeks to months).
Pelllegrini-Stieda lesion
Ossified post-traumatic lesions at the MCL adjacent to the femoral attachment site of the medial femoral condyle.
Mechanism is likely from an avulsion injury that subsequently calcifies after the initial trauma.
Often an incidental finding on plain films.
If symptomatic, refer to ortho as an outpatient
If not symptomatic, no treatment is indicated
http://images.radiopaedia.org/images/30076/b62e61e83241e30f2da693901edcdc_gallery.jpg
http://www.imageinterpretation.co.uk/images/knee/PELLEGRINI%20STIEDA2.jpg
No single feature of the history of physical examination reliably rules out ostemyelitis
Aids in making the diagnosis include:
An ulcer area larger than 2 cm2 (LR 7.2),
A positive probe to bone test (LR 6.4),
An ESR greater than 70 mm/h (LR 11)
Treating knee osteoarthritis - from the American College of Rheumatology
Exercise whether it be aquatic, aerobic (land -based) or resistance can decrease pain and improve functional capacity. Exercise should be performed 3 to 5 times a week. Effects are usually noted after 3 to 6 months.
Weight loss of 5% or greater body weight is associated with a small improvement in pain and physical function. The main benefit of weight loss has more to do to effects on co-morbid conditions.
Walking aids: A single crutch or cane should be held on the side contralateral to the affected knee and should be advanced with the affected limb when walking to reduce the load on the affected joint.
Cane sizing: The distance from the floor to the patient's greater trochanter (brings the elbow to 15º to 20º of flexion.
